Get Form Hs10094 Authorization For Release Of Health Records.doc

Filling out the Form HS10094 is an essential process for authorizing the release of your health records. This guide provides clear, step-by-step instructions to assist you in completing the form online with ease and confidence.

Follow the steps to complete the form effortlessly.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the patient’s name in the designated field. Ensure that you provide the full legal name as it appears on medical records.
3. Input the date of birth. Use the format MM/DD/YYYY to avoid any confusion.
4. Fill in the patient’s address, including city, state, and ZIP code. Make sure this information is current to ensure proper communication.
5. Provide the contact telephone number by filling in the appropriate field.
6. Identify the organization authorized to make the disclosure by providing the facility name and address.
7. Indicate the date(s) of treatment relevant to the release of records in the 'From' and 'To' fields.
8. Select the types of information to be released by checking all applicable boxes, including medical history, discharge summary, and lab results.
9. Complete the details for the individual or organization that will receive the health records, including their name, address, and contact information.
10. Specify the reason for the disclosure by checking the appropriate box and adding additional details in the provided field if necessary.
11. Read the section about the potential risks of disclosure, especially concerning sensitive health information, and confirm your understanding.
12. Sign and print the patient’s name in the designated signature section, along with the date of signing.
13. If applicable, have a legal representative sign and provide their relationship and authority in the subsequent sections.
14. Review all filled information for accuracy before finalizing.
15. Once completed, save changes, download a copy, print it, or share the form as necessary.

Complete your documentation process online for a smooth health records release experience.